The GABAB antagonist CGP 35348 inhibits the effects of baclofen on sexual behavior and motor coordination

Management of Recurrent Ischemic Priapism 2014: A Complex Condition with Devastating Consequences

INTRODUCTION

The management of recurrent ischemic priapism (RIP) is not clearly defined. Given the rarity of this condition, most treatment options are supported at best by level 3 or 4 evidence.

AIM

In this article, we review the current literature regarding the pathophysiology and management of RIP and discuss the risks and benefits associated with each option, which includes ketoconazole (KTZ), 5-α-reductase inhibitors and other hormonal therapies, phosphodiesterase type 5 (PDE5) inhibitors, intracavernosal sympathomimetic injection, oral sympathomimetic agents, and other investigational therapies.

METHODS

A comprehensive literature review was performed regarding the management options for RIP.

MAIN OUTCOME MEASURE

To examine the pathophysiology of RIP and evaluate the treatment options.

RESULTS

Multiple agents have been investigated to manage RIP. KTZ, finasteride, anti-androgens, gonadotropin-releasing hormone agonists, and estrogen have been shown to be effective in several reports, though some of these agents may have significant hormonal side effects. PDE5 inhibitors currently appear to be well tolerated in this patient population, though evidence of its efficacy is limited. Intracavernosal α-agonist therapy may be used to treat episodes of priapism after they occur. Very limited data suggest terbutaline, oral α-agonists, digoxin, hydroxyurea, and gabapentin may have a role in RIP management.

CONCLUSIONS

An ideal management strategy for RIP should focus on prevention of priapic episodes using an effective, well-tolerated, cost-effective medication. We currently have several proposed options, with varying efficacy rates and side effect profiles. While significant advancements in our understanding and management of stuttering priapism have been made within the past few years, clearly continuing research and clinical studies are needed to guide our management of this disease process. Hoeh MP and Levine LA. Management of recurrent ischemic priapism 2014: A complex condition with devastating consequences. Sex Med Rev 2015;3:24-35.

Medical management of ischemic stuttering priapism: a contemporary review of the literature

Priapism is defined as a prolonged and persistent erection of the penis without sexual stimulation. This is a poorly understood disease process with little information on the pathophysiology of this erectile disorder. Complications from this disorder are devastating due to the irreversible erectile damage and resultant erectile dysfunction (ED). Stuttering priapism, though relatively rare, affects a high prevalence of men with sickle-cell disease (SCD) and presents a challenging problem with guidelines for treatment lacking or resulting in permanent ED. The mechanisms involved in the development of priapism in this cohort are poorly characterized; therefore, medical management of priapism represents a therapeutic challenge to urologists. Additional research is warranted, so we can effectively target treatments for these patients with prevention as the goal. This review gives an introduction to stuttering priapism and its clinical significance, specifically with regards to the patient with SCD. Additionally, the proposed mechanisms behind its pathophysiology and a summary of the current and future targets for medical management are discussed.

Favorable response to intrathecal, but not oral, baclofen of priapism in a patient with spinal cord injury

STUDY DESIGN

Case report.

OBJECTIVE

To retrieve data about the utility of intrathecal baclofen for the treatment of otherwise refractory priapism that may occur in patients with spinal spasticity.

SUMMARY OF BACKGROUND

Baclofen exerts well-known inhibitory effects on sexual function both in animals and humans. This observation led to the introduction of oral baclofen in the treatment of refractory and recurrent idiopathic priapism.

METHODS

We report a 41-year-old male patient who sustained a severe traumatic spinal cord injury in a motor vehicle accident. On clinical examination he presented with tetraplegia (motor level C3). Initial cervical magnetic resonance imaging showed a C3 to C4 lesion with a herniated disc and compression of the dural sac. One month later the patient developed priapism episodes.

RESULTS

He received oral baclofen with only minimal beneficial effect on priapism. Eight months postinjury the patient underwent a test-trial with intrathecal baclofen bolus, which caused absence of priapism for 10 hours. One month later, an intrathecal pump system was implanted, leading to absence of priapism episodes.

CONCLUSION

In the present case report, reduction of supraspinal control on the spinal cord may have induced an up-regulation of GABAB receptors, which are involved in penile tumescence. The trauma induced also liberation of penile reflexes with episodes of priapism. Normal full blood count and color duplex ultrasonography of the penis excluded a vascular genesis of priapism. This is the first report about the utility of intrathecal baclofen for the successful control of otherwise untreatable priapism in a patient with severe spinal spasticity. Hence, evaluation of intrathecal baclofen should be considered in patients suffering from severe and/or frequent priapism when oral baclofen and/or hormonal therapy are ineffective. The beneficial effect of intrathecal, but not oral baclofen, in our patient suggests a dose-dependent effect.

Moxidectin interference on sexual behavior, penile erection and hypothalamic GABA levels of male rats

The moxidectin (MXD) is an antiparasitic drug used in domestic animals. The mechanism of action, in mammals, involves GABA, a neurotransmitter with an important role in the sexual behavior control. Presently, the effects of 0.2 mg/kg therapeutic dose were studied on sexual behavior, sexual motivation, penile erection and central GABA levels. Sexual behavior results showed increased latencies to the first mount and intromission as well as in inter-intromission interval; a reduction in total mounts was detected on the drug post-treatment. No difference was observed between sexual motivation of control and experimental animals. MXD treatment reduced penile erection and hypothalamic GABA levels. The results suggest that MXD reduced sexual behavior and penile erection by an action on the hypothalamic GABA system. Probably, the lack of effects in the motivational test and the increased mount and intromission latencies as well as decreased total mounts could be explained as a consequence of reduced male rat erection process.

Multi-target strategies for the improved treatment of depressive states: Conceptual foundations and neuronal substrates, drug discovery and therapeutic application

Major depression is a debilitating and recurrent disorder with a substantial lifetime risk and a high social cost. Depressed patients generally display co-morbid symptoms, and depression frequently accompanies other serious disorders. Currently available drugs display limited efficacy and a pronounced delay to onset of action, and all provoke distressing side effects. Cloning of the human genome has fuelled expectations that symptomatic treatment may soon become more rapid and effective, and that depressive states may ultimately be "prevented" or "cured". In pursuing these objectives, in particular for genome-derived, non-monoaminergic targets, "specificity" of drug actions is often emphasized. That is, priority is afforded to agents that interact exclusively with a single site hypothesized as critically involved in the pathogenesis and/or control of depression. Certain highly selective drugs may prove effective, and they remain indispensable in the experimental (and clinical) evaluation of the significance of novel mechanisms. However, by analogy to other multifactorial disorders, "multi-target" agents may be better adapted to the improved treatment of depressive states. Support for this contention is garnered from a broad palette of observations, ranging from mechanisms of action of adjunctive drug combinations and electroconvulsive therapy to "network theory" analysis of the etiology and management of depressive states. The review also outlines opportunities to be exploited, and challenges to be addressed, in the discovery and characterization of drugs recognizing multiple targets. Finally, a diversity of multi-target strategies is proposed for the more efficacious and rapid control of core and co-morbid symptoms of depression, together with improved tolerance relative to currently available agents.

Electrophysiological and neurochemical characterization of neurons of the medial preoptic area in Japanese quail (Coturnix japonica)

Intracellular recordings of medial preoptic neurons demonstrated that most neurons show a spontaneous firing, a linear I-V relationship and low-threshold-like events suppressed by the application of Ni2+. Some neurons had a depolarizing sag of the membrane potential in response to hyperpolarizing current pulses. The majority of the cells exhibited a robust spontaneous synaptic activity suppressed by SR95531 (100 microM), a GABAA receptor antagonist, and/or by 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX, 10 microM), an (RS)-alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid (AMPA)/kainate (KA) glutamate receptor antagonist. Most neurons were affected by the application of AMPA (10 microM), kainate (30 microM), N-methyl-D-aspartic acid (NMDA, 10 microM), isoguvacine (a GABAA receptor agonist, 100 microM), dopamine (100 microM), and norepinephrine (100 microM). Biocytin injections coupled to aromatase immunocytochemistry identified 19 recorded neurons including 3 displaying a dense aromatase immunoreactivity. All of them responded to kainate, dopamine, and norepinephrine, while only one responded to isoguvacine and NMDA. Taken together, these results demonstrate a relative electrical and neurochemical homogeneity of the medial preoptic neurons, including a few aromatase-immunoreactive neurons that could be identified by immunocytochemistry after biocytin labeling of the recorded neurons.

Molecular structure and physiological functions of GABA(B) receptors

GABA(B) receptors are broadly expressed in the nervous system and have been implicated in a wide variety of neurological and psychiatric disorders. The cloning of the first GABA(B) receptor cDNAs in 1997 revived interest in these receptors and their potential as therapeutic targets. With the availability of molecular tools, rapid progress was made in our understanding of the GABA(B) system. This led to the surprising discovery that GABA(B) receptors need to assemble from distinct subunits to function and provided exciting new insights into the structure of G protein-coupled receptors (GPCRs) in general. As a consequence of this discovery, it is now widely accepted that GPCRs can exist as heterodimers. The cloning of GABA(B) receptors allowed some important questions in the field to be answered. It is now clear that molecular studies do not support the existence of pharmacologically distinct GABA(B) receptors, as predicted by work on native receptors. Advances were also made in clarifying the relationship between GABA(B) receptors and the receptors for gamma-hydroxybutyrate, an emerging drug of abuse. There are now the first indications linking GABA(B) receptor polymorphisms to epilepsy. Significantly, the cloning of GABA(B) receptors enabled identification of the first allosteric GABA(B) receptor compounds, which is expected to broaden the spectrum of therapeutic applications. Here we review current concepts on the molecular composition and function of GABA(B) receptors and discuss ongoing drug-discovery efforts.

GABA(B) receptor agonists for the treatment of drug addiction: a review of recent findings

A growing preclinical and clinical literature suggests that GABA(B) receptor agonists promote abstinence and reduce the use of cocaine, heroin, alcohol and nicotine. The purpose of this paper is to critically review these data. GABA(B) receptor agonists, such as baclofen, appear to reduce the reinforcing effects of abused drugs in animal models under multiple experimental procedures. This occurs at doses that have little effect on responding for other positive reinforcers such as food or water. We review evidence that these potential therapeutic effects may be mediated by modulation of mesolimbic dopamine neurons. This review also examines the preliminary clinical data from studies of the efficacy of baclofen for treatment of cocaine, alcohol, and nicotine dependence. We suggest that these preliminary data provide a rationale for conducting more systematic studies of the effects of GABA(B) receptor agonists as treatment for drug abuse. This line of research may also improve our understanding of the neurochemical mechanisms underlying the drug dependence process.

GABAergic drugs and sexual behaviour in the rabbit: evidence for species-specific effects

The effects of gamma-amino butyric acid (GABA)-ergic drugs on male rabbit sexual behaviour have been evaluated. The GABA(A) agonist 4,5,6,7-tetrahydroxixazolo-5,4c-pyridin-3-ol (THIP), the GABA(B) agonist R-baclofen and the GABA antagonists picrotoxin and bicuculline were used. Injection of THIP, 20 mg/kg, s.c. produced a complete suppression of sexual behaviour and R-baclofen, 2.5 mg/kg, s.c. a significant inhibition. Intraperitoneal injections produced effects at higher doses than did s.c. injections. The inhibition produced by R-baclofen was associated with strong motor effects as shown by the water escape test. It is probable, therefore, that the reduced sexual behaviour observed after treatment with this drug is a consequence of sedative or muscle relaxant effects. By contrast, the dose of THIP that inhibited sexual behaviour had no effect on the water escape test. These results show that the GABA(A) agonist inhibits sexual behaviour in the male rabbit independent of effects on the motor system. The GABA antagonists had marginal or no effects on sexual behaviour. When these data are compared to previous results in the rat, substantial differences are seen. As there are differences between the effects on rat and rabbit sexual behaviour by other types of drugs, it appears that drug action on sexual behaviour cannot be generalized from one species to another.

Interactions between dopamine and GABA in the control of ambulatory activity

Ambulatory activity of male rats was quantified in an open field. The subjects were treated with DL-amphetamine and amfonelic acid alone or combined with the GABA transaminase inhibitors gamma-acetylen GABA (GAG) and sodium valproate as well as with the GABAA agonist THIP and the GABAB agonist baclofen. Subeffective doses of the GABAergic drugs did not modify the effects of moderate doses of the dopaminergic stimulants whereas effective doses continued to reduce ambulatory activity just as in the absence of dopaminergic activation. When DL-amphetamine or amfonelic acid were administered in doses that strongly enhanced ambulatory activity, doses of the GABAergic drugs that were inhibitory in the absence of dopaminergic stimulation were no longer effective. The mixed D1/D2 dopamine antagonist pimozide, the D1 antagonist SCH 23390 and the D2 antagonist sulpiride were then combined with subeffective doses of the GABA agonists. GAG, sodium valproate and baclofen were potentiated by pimozide and SCH 23390 but not by sulpiride. THIP was ineffective. These data show that GABAergic drugs had a reduced effect after stimulation of dopaminergic neurotransmission. On the other hand, when dopamine D1 receptors were blocked, nonselective GABA agonists and the GABAB agonist baclofen were potentiated. This was not the case for the GABAA agonist THIP, suggesting that the GABAA receptor is of slight importance for the interactions between GABA and dopamine in the control of ambulatory activity. No potentiation of GABAergic agonists was obtained after treatment with a dopamine D2 antagonist.